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(p. 52) Barriers and Facilitators to Acceptance of Mental Illness 

(p. 52) Barriers and Facilitators to Acceptance of Mental Illness
Chapter:
(p. 52) Barriers and Facilitators to Acceptance of Mental Illness
Author(s):

Lauren Mizock

and Zlatka Russinova

DOI:
10.1093/med:psych/9780190204273.003.0004
Page of

date: 14 October 2019

The process of acceptance is not an easy road, and people with serious mental illness have described the roadblocks that stand in their way on this path.1 People with mental illness may benefit from supports and resources that are vital to attaining this state. Previous research has hinted at these barriers and facilitators to the process of acceptance of mental illness, but this research has been primarily theoretical in nature, or focused on acceptance of a slightly related construct, such as a physical disability or a psychiatric diagnosis.

For example, prior researchers have speculated that facilitators might include effective coping and the support and acceptance of others, while barriers could include shame, stigma, and negative self-judgment (Spaniol & Gagne, 1997). In an empirical study on acceptance of physical disability, a number of potential facilitators to this neighboring process were proposed, such as the emotional and social support of family and friends (Li & Moore, 1998). Barriers to acceptance of disability included negative self-judgment, perceived social discrimination, mistreatment from providers, chronic pain, and multiple disabilities.

In their study of acceptance of a bipolar disorder diagnosis, Inder and colleagues (2010) found facilitators to this process to be psychoeducation, positive experiences with providers, and enhanced management of symptoms. Barriers to acceptance included changing diagnoses, misdiagnosis, mistreatment, mistrust toward providers, negative side effects, and difficulties separating one’s sense of self from the diagnosis.

Roe and Kravetz (2003) identified a small number of potential barriers to insight about one’s mental illness. In this theoretical article, the authors argued that insight, awareness, and recognition of one’s psychiatric disorder can be (p. 53) developed in the form of a narrative or story one tells about one’s illness as opposed to a set of beliefs about one’s symptoms. These authors also described deterrents to insight, such as a pessimistic prognosis associated with mental illness and feelings of helplessness or hopelessness.

Facilitators and Barriers to Acceptance of Mental Illness

With this limited literature, we can see that additional investigation is needed to further identify the barriers and facilitators to the process of acceptance of mental illness. Although researchers have previously discussed facilitators and barriers in the process of acceptance of specific diagnoses or disabilities, they have lacked a broader focus on serious mental illnesses in general. Though a small number of facilitators and barriers have been suggested within the few existing articles on this topic, a more comprehensive list and category system would delineate this process more clearly. In our qualitative research, we have asked people with serious mental illness to talk about what has helped them with feeling acceptance, and what tends to stand in their way. In this section, we organize their responses with categories and themes using grounded theory analysis, as summarized in Table 4.1.

Table 4.1. Factors in the Acceptance of Mental Illness

Levels

Factors

Definitions

Micro

Emotional

Feelings, mood, and affect that facilitate or pose barriers to acceptance of mental illness.

Behavioral

Engaging in actions and activities that facilitate or pose barriers to acceptance of mental illness.

Cognitive

Thoughts, beliefs, and awareness that facilitate or pose barriers to acceptance of mental illness.

Identity

Developing a sense of self in the face of mental illness that facilitates or poses barriers to acceptance of mental illness.

Meso

Relational

Interactions and engagement with others in a manner that facilitates or poses barriers to acceptance of mental illness.

Macro

Cultural

Values, beliefs, practices, and stigma associated with an individual’s demographic group that facilitate or pose barriers to acceptance of mental illness.

Spiritual & Religious

Beliefs, practices, communion with the divine or transcendent, and connection to religious and spiritual organizations that facilitate or pose barriers to acceptance of mental illness.

Systemic

Healthcare, employment, and governmental policies and practices that facilitate or pose barriers to acceptance of mental illness.

Adapted with permission from Mizock, L., Russinova, Z., & Millner, U. (2014). Barriers to and facilitators of the acceptance process for individuals with serious mental illness. Qualitative Health Research, 24(9), 1265–1275. Copyright © 2014, SAGE Publications.

Barriers and facilitators at the micro and meso level correspond with the internal and relational dimensions of acceptance, as seen in Table 4.2. In this table, barriers and facilitators also occur at the macro level. These macro-level barriers and facilitators surpass the individual and interpersonal dimensions of acceptance in Chapter 3. Individual and interpersonal components of acceptance are centered inside the individual and in their relating with others. Macro barriers and facilitators to the acceptance process generally involve factors outside of the person. For the barriers and facilitators of acceptance, we used the terminology of developmental psychology researcher Urie Bronfenbrenner to name facilitators and barriers at the micro (individual), meso (interpersonal), or macro (cultural–spiritual–religious–systemic) levels. Let’s begin with the micro level.

Table 4.2. Acceptance of Mental Illness Dimensions, Barriers, and Facilitators

Levels

Dimensions

Barriers & Facilitators

Micro

Emotional

Emotional

Behavioral

Behavioral

Cognitive

Cognitive

Identity

Identity

Meso

Relational

Relational

Macro

Cultural

Spiritual & Religious

Systemic

Micro Level: Individual Facilitators and Barriers

Emotional Facilitators and Barriers

Participants in our research have described a number of emotional barriers and facilitators to the acceptance process—feelings that interfered with or fostered this process. Emotional barriers included shame, fear, guilt, frustration, and hopelessness. For example, when we asked, “What gets in the way of accepting psychiatric problems?” one person replied: “Feeling down. When you feel down, (p. 54) (p. 55) and when you can’t get a job because of past experiences and because you know you’re going to be in the hospital soon anyway, so there’s no point.” Another participant seconded this sense of defeat as standing in the way of acceptance, stating, “Frustration [gets in the way of acceptance]. Nothing’s happening. Why bother? So, [you feel] less hope.” Adding to the difficult emotions that could interfere with acceptance was a sense of self-blame: “I felt guilty,” was stated by one participant. He found that this guilt made it “really hard to accept depression.” Challenging feelings could shut the person down and interrupt the process of recognizing and dealing with the mental illness.

On the other hand, some difficult emotions could have a motivating quality. One person identified the central facilitator to his acceptance as: “Fear. Fear of losing my stability, my home, my money, my mind, to be in control. Those things [made me accept it].” Other positive emotions clearly facilitated the acceptance process, such as hope, humor, love, and pride. This experience was summed up by one participant who indicated that acceptance was boosted by the potential for happiness. “If I could experience certain things that would bring me happiness. The hope that that could happen gets me through the day, honestly… . Hope and acceptance. Acceptance of my illness.”

Behavioral Facilitators and Barriers

Many people described behavioral facilitators and barriers in the acceptance process, which we define as the process of engaging in actions and behaviors that foster or hinder acceptance of one’s mental illness. Behavioral barriers included avoidant behaviors, like inactivity, or maladaptive behaviors, like substance abuse. For example, one person recalled, “Before [acceptance] I wouldn’t say anything; I would just sleep, sleep, sleep.” Withdrawing from the world in this way interfered with facing the reality of his mental illness and managing it more effectively. Another person spoke to the avoidant behavior that could arise from denial. “It’s hard sometimes because I’ve gone off my meds several times… . So that’s part of accepting my mental illness, is being dedicated to medicine.”

In contrast, behavioral facilitators to acceptance included taking appropriate medication, engaging in mindfulness techniques, going to work, and writing. One person gave an example of this type of facilitator: “I just accept [that] for whatever reason they feel I have a diagnosis of schizophrenia, and that I accept it for what it is. And I take the medicine for it, and I keep current with [my mental health program].” Accepting the mental illness naturally entailed a series of behaviors that, in turn, encouraged the acceptance process. Other positive activities could also support acceptance. One participant found writing in a gratitude journal to be especially helpful with acceptance: “Every day before I go to bed I have to write something positive in this notebook … It just gives me a habit of [asking], did anything go good? … I think it’s been helpful to me.” Writing to reflect on positive behaviors could create this cycle of reflection, (p. 56) positive emotion, and further engagement in adaptive behavior that advances the acceptance process.

Cognitive Facilitators and Barriers

Participant responses included a category of cognitive facilitators and barriers to the acceptance process of mental illness, referring to thoughts, beliefs, and awareness surrounding acceptance of one’s mental illness. Cognitive barriers included a lack of clarity or engaging in negative thinking. One person described his trouble with accepting his mental illness given changes in his cognition: “It can be a little stifling when you can’t really think. It can be oppressive when you can’t concentrate on things.” Some people defined the opposite of acceptance as a cognitive state of denial, sometimes leading to suicidality. For example, one person stated: “Really what gets in the way of accepting for me, is denial … it was not healthy. And it damn near cost me my life.”

Cognitive facilitators included recognizing when one needs help and being aware of one’s strengths or the positive outcomes of the illness. Additionally, self-education, self-reflection, and self-knowledge could promote acceptance. Lastly, engaging in positive thinking and beliefs about the illness were essential cognitive facilitators of acceptance. For example, one person was asked about what facilitated acceptance and spoke of the importance of knowledge and awareness in furthering acceptance. “Just thinking about what’s going on with me. Just knowing my issues, just knowing my problems, just knowing how I act on a regular basis, that I accept it.” Another person identified facilitators to acceptance as including cognitive awareness and mindfulness. “Some of the basic concepts of mindful awareness, and just the very basics of it, think in the present, not in the future or the past.”

Identity Facilitators and Barriers

Another category emerged in our research pertaining to identity-related barriers and facilitators to the development of a positive sense of self in spite of the mental illness. Identity-related barriers included internalizing negative identities as a mental patient, such as being inferior, disabled, untrustworthy, dehumanized, or dependent. When asked about barriers to acceptance, one participant described this negative sense of self that gets in the way of acceptance: “So, in terms of accepting my illness, it’s like I don’t want to be put in discarded terms of like, I need this, I need that, I can’t do this, I have to do this. I don’t want to accept that I can’t move on or be successful and live a bright future. I definitely don’t want to accept that.” In the absence of acceptance, some also reported a negative sense of self to the point of suicidality. One person described this experience: “Sometimes when I’m depressed, I just (p. 57) think I suck, and that I’m a bad person, and I really [feel] I shouldn’t be in this world and things like that.”

Identity-related facilitators to the acceptance process included becoming and seeing oneself as compassionate, a role model, an advocate, a support to others, and a whole person beyond just a diagnosis. One person described a facilitator to her acceptance process as being an advocate for others, indicating: “I can speak to someone and advocate for them. That I can say like, ‘Listen, yeah, you know, listen. This is what happened to me. This may or may not be what happened to you, so let’s talk about this.’ ”

Meso Level: Relational Facilitators and Barriers

Many of the people we spoke with described relational barriers and facilitators to the acceptance process, which we define as interactions and engagement with others in a manner that promotes acceptance of the illness. Relational barriers might include lack of acceptance or discouragement from others. One participant described these experiences: “When other people don’t accept you as you are, it’s really hard to accept depression.” Another participant described relational barriers to acceptance: “It’s people … scapegoating me out of a crowd or something. And then I feel like maybe I’m a bad person, so I don’t accept myself.”

The majority of participants described relational facilitators, including feeling accepted by others, as well as socializing, talking with, and accepting help and encouragement from others. Other relational facilitators included connecting to positive role models and doing positive things for others, such as advocating or feeling compassion for others, or carrying out parenting responsibilities. Participants described a number of interpersonal facilitators, such as support of groups, communities, peers, peer specialists, providers, partners, families, and teachers. One person discussed the value of connecting with peers with similar mental illness experiences: “It’s like, you know they have the same problems you do, the same situations, and it really helps me accept myself.” Another person spoke about the impact of this acceptance from others: “To be accepted by other people … helps me a lot… . For people to sympathize with me … [helps with] accepting who I am.”

Macro Level: Cultural and Systemic Facilitators and Barriers

Cultural Facilitators and Barriers

Cultural facilitators and barriers in the acceptance process comprised values, beliefs, practices, and stigma associated with one’s cultural group. Cultural (p. 58) barriers included stigma related to cultural explanatory models of mental illness that contributed to isolation from one’s cultural group. It is important to note that cultural facilitators and barriers can occur simultaneously at micro, meso, and macro levels. Given that cultural facilitators and barriers reach a maximum level of “macro,” and often occur on a macro level, we categorized it as macro level in the present analysis.

A Cape Verdean man identified cultural barriers to his acceptance of mental illness: “Only thing about Cape Verdeans, they don’t accept people who have mental illnesses. Like, a lot of cultures understand it, but they, I think Cape Verdeans don’t want to understand it.” Another person discussed barriers to acceptance of his mental illness that he felt originated in stigma toward mental illness in his culture: “They don’t accept mental health. Basically, if you’re diagnosed with a mental disease, then you’re an outcast, a failure in the family, like married wrong and so on.” A European American woman described stigma in American culture as interfering with her acceptance of her mental illness: “In America you’re not supposed to be depressed, and if you are you’re supposed to snap out of it, pull yourself up by your bootstraps.”

Cultural facilitators included explanatory models of mental illness that were nonstigmatizing, awareness of stigma in one’s culture, taking action against cultural stigma, as well as cultural community supports. One woman identified a support group for women of color as helpful to fostering her acceptance of mental illness: “Being a person of color, it’s not something that’s culturally talked about. So, that’s how [this group] got started, as a way to get people in touch with mental health services and to get people to actually take care of themselves.” These community supports provide a sense of cultural affirmation and fellowship that fostered acceptance.

Spiritual and Religious Facilitators and Barriers

Spiritual and religious facilitators and barriers to the acceptance process refers to beliefs, practices, communion with the divine or transcendent, and connection to religious and spiritual organizations. Spiritual and religious barriers included feeling punished by God, anger at God, or mental illness stigma within one’s religion. One person described religious barriers to accepting one’s mental illness as involving, “falling victim to the religious people who are just like, ‘All you have to do is embrace God and everything will just go away.’ Or … it’s something you did wrong, and God doesn’t love you because of it, and so nobody needs to either… . Or thinking that this is a punishment.” When another person was asked about barriers to her acceptance process, she described spiritual and religious views: “Some people who are New Age or Pagan believe that you’re reincarnated. It makes me wonder why I would have chosen this. That you have a choice of what your life is… . It’s one of the things that gets in the way of my acceptance, because I wonder why I would have chosen to be broken.”

(p. 59) Spiritual and religious facilitators for accepting mental illness included prayer, talking to God, meditation, and church attendance. Individuals involved with these developed a positive sense of spirituality and connection to one’s religion. One participant described facilitators to her acceptance process as: “Spirituality and religion. Going to church. And right now, I’m looking for a new church home. I’ve been going to different churches, looking for a good church home, something I can identify to.” Another participant described Buddhist beliefs as a facilitator: “I have accepted it a lot more than in the past … [through] Buddhist practice… . It’s always about, ‘Okay, you’ve had this setback,’ and that you know that you can sort of get better again.”

Systemic Facilitators and Barriers

Systemic barriers to the acceptance process included barriers and facilitators at the broader, institutional level, such as health care, employment, and governmental policies and practices. One person described such barriers as, “stigma, the media, [and] maybe old school psychiatric processes that aren’t really focused on recovery.” Another participant described work barriers to the acceptance process: “If I were turned down on [a work] application, I’d feel bad about it… . They don’t really say that that’s the reason, but sometimes they imply it though. So, they want me to be healthy at work, and I hope to be healthy at work.”

Systemic facilitators to the acceptance process included institutional supports such as health insurance, financial resources for people with mental illness, a supportive mental health system, and vocational rehabilitation systems. One person described systemic facilitators this way: “I’m seeing a lot of organizations and programs that are more recovery-oriented now. And I think that’s what’s really made me get better. Because they’re focusing on daily living and just getting better and having a meaningful life, and having a social network.”

Understanding the Barriers and Facilitators to Acceptance

A number of barriers and facilitators to the process of acceptance of mental illness emerged from the data, as seen in Table 4.1. We applied Bronfenbrenner’s (1979) ecological systems theory to categorize the multiple levels at which acceptance of mental illness might occur at the micro (individual), meso (interpersonal), and macro (cultural, systemic, spiritual, and religious) levels. These results suggest that people with mental illness can work on self-acceptance at the individual level, but are also impacted by facilitators and barriers to acceptance at the interpersonal and systemic levels.

Participants described the acceptance process as not only involving self-acceptance, but also feeling acceptance by others. This finding supports a (p. 60) previous emphasis placed on acceptance of people with mental illness among the public (Angermeyer, Holzinger, Carta, & Schomerus, 2011; Karp & Tanarugsachock, 2000; Lauber, Nordt, Sartorius, Falcato, & Rossler, 2000). Our interviews indicated that one’s acceptance of mental illness can be facilitated by acceptance from other people and systems (e.g., family, partners, therapists, community, culture, media, or organizations). These results are supported by the psychiatric rehabilitation literature, which places importance on one’s relationships with providers and natural supports in fostering recovery from serious mental illness (Anthony, Cohen, Farkas, & Gagne, 2002; McCabe & Priebe, 2004). Moreover, findings with regard to systemic facilitators and barriers in acceptance correspond with positive psychology theory. Researchers in the positive psychology field have discussed a “group level” factor in well-being, in which institutions play a key role in promoting happiness and life satisfaction (Seligman & Csikszentmihalyi, 2000).

Our findings on public and personal acceptance highlight the impact of stigma on the acceptance process. People we spoke to reported feelings of shame, rejection by others, cultural stigma, and lack of inclusion in institutional sectors as interfering with their own acceptance process. Previous literature has suggested that because of stigma, many people with mental illness do not seek treatment (Cooper, Corrigan, & Watson, 2003). Additionally, the research has indicated that people with mental illness encounter stigma when interacting with medical and mental health professionals, as well as in their interpersonal social networks (Corrigan, 2004). Our findings add to this literature, suggesting that stigma can interfere with self-acceptance of mental illness across individual, relational, cultural, and systemic levels.

Applications to Clinical Work

A number of clinical implications emerge from these findings. For one, facilitators and barriers were found at the individual level with regard to identity-related facilitators and barriers. Providers can work with people with mental illness individually to facilitate acceptance by promoting a positive sense of self in the face of mental illness. This identity process can be encouraged through the recognition of one’s strengths in spite of challenges, as well as the protection and preservation of a positive sense of self in spite of the illness. These results are reinforced in the positive psychology literature, which has underscored the importance of therapists learning about the goals of people with mental illness and utilizing their strengths to promote recovery and well-being (Slade, 2010). Clinicians can address ambivalence toward mental illness to facilitate added levels of acceptance and help to integrate them into a positive sense of self. Therapists might also inquire about clients’ attitudes toward themselves and toward mental illness and explore the associated impact on acceptance. (p. 61) Therapists can challenge negative self-attributions, and reinforce positive and constructive self-perceptions.

Our findings also suggest that providers might work with clients to identify cognitive, emotional, behavioral, relational, cultural, institutional, and spiritual or religious strategies to facilitate acceptance. Clinicians can recognize that clients might face barriers to acceptance of mental illness that result in denial, a lack of self-advocacy, and even suicidality. Given our results regarding relational and systemic facilitators and barriers in acceptance, clinicians can be sensitive to the ways in which one’s relationship to one’s therapist, family, community, workplace, culture, and government might interfere with or facilitate the acceptance of mental illness. Specifically, therapists can investigate the nature of these relationships, systems, and supports in the client’s life and help to bolster a support network.

Clinicians can consider utilizing a number of established therapeutic approaches to facilitate the acceptance process for people with mental illness and help them overcome barriers. With a recovery-oriented and positive psychology approach toward mental illness, providers can facilitate acceptance through instilling hope; providing interpersonal, vocational, and community supports; counteracting stigma; and emphasizing strengths and well-being (Farkas & Anthony, 2010; Slade, 2010). These approaches can address the emotional, relational, and systemic facilitators of the acceptance process. Clinicians can provide culturally responsive mental health care by developing a sensitivity to the cultural facilitators and barriers that might contribute to the client’s acceptance process (Ida, 2007; Mizock & Russinova, 2013). Practitioners can explore cultural facilitators and barriers to acceptance with their clients and connect them to relevant resources in the community so that clients can feel more supported within their cultural network. We will describe cultural issues in acceptance further in Chapter 8.

Conclusion

Providers can support cognitive, emotional, behavioral, and identity-related facilitators and barriers in the acceptance of mental illness at the micro level. Relational, cultural, systemic, and spiritual/religious supports at the meso and macro levels are critical to enhancing one’s acceptance of mental illness. Acceptance of mental illness should be viewed as a societal process as well as an internal process because of barriers related to mental illness stigma and lack of public acceptance. Acceptance of mental illness is not simply an individual endeavor but involves the effort of the larger community. Consumers, clinicians, peers, and other advocates can engage in activism and policy change to promote acceptance of mental illness within the individual and the general public.

(p. 62) Clinical Strategies

  • Have clients identify what gets in the way of their acceptance process (barriers) and what helps to move their acceptance process forward (facilitators).

  • Pinpoint the cognitive, emotional, behavioral, spiritual, or religious facilitators and barriers that help or hinder the acceptance process.

  • Open up a discussion with the client as to the ways you can help facilitate acceptance for the person. Identify if there are times when you may not be helpful to the acceptance process. Explore ways to enhance acceptance in your work together.

  • Identify how people in the client’s social network—family, friends, significant others, peers, helpers, or other relationships—support or interfere with the acceptance process. Identify what aspects of these relationships could be helpful or harmful to acceptance.

  • Consider engaging the client family or partner of the client in therapy to address how they might interfere with or enhance acceptance in the person’s life.

  • Explore the individual’s culture and identify what cultural resources or challenges facilitate or interfere with acceptance.

  • Locate institutions and systems in the client’s life that may support or deter acceptance (e.g., mental health service facilities, workplaces, community organizations).

  • Help the person to access relevant resources in the community to enhance support and acceptance within the client’s community and cultural network. For example, people can be supported to connect to a spiritual congregation, cultural center, or other welcoming community that is affirming of people with various mental health experiences.

  • Discuss the impact of various sociopolitical facilitators and barriers in the acceptance process, such as the government, economy, and healthcare industry. Support the client in engaging in community action to overcome barriers at this level or consider becoming involved in your own advocacy or activism in this area to campaign for social change.

  • Help clients identify concrete steps to overcoming barriers and accessing facilitators to acceptance. Integrate these steps into the goals in a formal treatment plan or an informal plan with the client, implement these goals, and follow up on them.

(p. 63) Discussion Questions

  1. 1. Barriers to acceptance occur at individual, interpersonal, and systemic levels. Explain which barriers you think would be the most difficult to overcome. Explain which facilitators might be the most helpful for fostering acceptance. Provide related clinical experiences or personal examples that come to mind.

  2. 2. What types of clients might need to overcome added barriers to the process of acceptance of serious mental illness? What facilitators and barriers may predispose someone to a more difficult acceptance process? What resources might help these individuals to overcome these barriers?

  3. 3. To what degree do you feel clinicians have the power to facilitate a client’s acceptance process? To what degree might this process depend on the client’s readiness or other facilitators and barriers outside of the clinician’s control? What facilitators and barriers in the client’s life may influence readiness for acceptance?

Activities

  1. 1. Case presentation. Take a clinical case or presentation of someone in the media with a serious mental illness. How do you feel this person is doing in their acceptance process? What facilitators and barriers to acceptance occur for the person? What are the steps needed to resolve these barriers and implement facilitators?

  2. 2. Narrative exercise. Write about a time you had difficulty accepting something in your life. What facilitators and barriers contributed to your difficulty accepting this issue? What helped you to come to a place of acceptance? How does this personal reflection impact your ability to conceptualize promoting acceptance of mental illness clinically?

  3. 3. Theoretical models. Create a concept map depicting a model for changes in the person’s sense of self that might occur over time with the acceptance process, perhaps including the barriers and facilitators to this process. See the example in Figure 4.1.

(p. 64) (p. 65)


Figure 4.1 Example of a concept map depicting a theoretical model of the acceptance process.

Figure 4.1 Example of a concept map depicting a theoretical model of the acceptance process.

Barriers and Facilitators to Acceptance Worksheet

Notes:

1. Portions of this book chapter originally appeared in Mizock, L., Russinova, Z., & Millner, U. (2014). Barriers to and facilitators of the acceptance process for individuals with serious mental illness. Qualitative Health Research, 24(9), 1265–1275. DOI: 10.1177/1049732314545889. Copyright © 2014, SAGE Publications. Adapted with permission.